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,oPquv 1"•.�o Wan Joaquin County �n <br /> 2 z Environmental Health Department W ( li`SITE <br /> m ` 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 r <br /> MI I'GATION <br /> P' (209)468-3449 Fax: (209)468-3433 Web: www.co.sanjoaquin.ca.us/eAMY 1 7 20Q4NIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONME HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ThispppIMItT/Sion iRV compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �35IT ��� 1#hr Assessors <br /> WELL Location Cross Streetl_ city Zip 53o Parcel# <br /> PROPERTY (� I G <br /> Owner LL �, a /L° Address 1 5. M� City //� Zipp/Phone#�rw�' <br /> C-57 Contractor 46"U p au� I Address •0. City a I {- Zip l�Lic# T66t hone#63n!587-201 C/ <br /> Consultant/ :Lr Addres;?6Z5 i.. Altue City,S_Lic# N!t' Phone# 2o7-yy$—/3yS <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/ BORIN (c GEOPROB , DROPU AND-AUGER,OTHER-) p DESTRUCTION <br /> 0 SOIL BORING# (choose type below) <br /> a WELL# a OVER-BORE. DIAMETER <br /> `Other I]PRESSURE GROUT <br /> _J, II 11 �t GROUT SPECIFICATIONS 711 �j <br /> COMMENTS: G.G. L1crWb A CAg+- * J .IDo/IAr-1 U(-G-fttA �I,V1-� a�,V►hl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL O PVC G OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE- MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_D OTHER APPROX.BORING DEPTH 1 f Q- O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED ) (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certif t at I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord'ria Ices ules and Regulations, and all applicable Californ' tate Laws. <br /> y <br /> Signed x Title/Company <br /> Print Name 1. <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: J� 6 (/ G <br /> Application Accepted By T� Date Issued s��O�� T AreaFSA q /-7 <br /> Grout Inspection By Date 20 Oy Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODETSF E INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVIC28.0 $5j— 89 1 Z / z� /Je </� SR# <br /> C-57_ WC----WAIVER— C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />